“I’m asking the Department of Defense and the Department of Veterans Affairs to work together to define and build a seamless system of integration with a simple goal: when a member of the Armed Forces separates from the military, he or she will no longer have to walk paperwork from a DoD duty station to a local VA health center; their electronic records will transition along with them and remain with them forever.” – President Barack Obama April 9, 2009

Last week I attended the DoD/VA EHR Integration and Interoperability Summit. It was an insightful opportunity that offered a lot of lessons on how stubborn and narrow-minded leadership can derail even the best intended projects being worked on by a committed and talented staff. It also served as a primer on how not to spend $1.3 billion dollars.

The conference was only two days, promised big name speakers, was held in Washington DC in early fall, and still drew a crowd of under 100. I was surprised. Maybe the iEHR saga isn’t as interesting to others as it is to me. Everyone in healthcare IT is understandably distracted with MU2 and ICD-10.

Still, iEHR was an important program, not only to veterans and soldiers but to anyone working in healthcare IT. iEHR would have been the single largest integrated EHR in the world, shared jointly between the VA and DoD’s combined 209 acute care facilities. It would have supported the largest group of employed clinicians in the country, with the VA employing more nurses, and clinical social workers than any other organization and ranking as one of the largest employers of physicians and PAs as well. With military personnel, qualifying veterans, and all of their families eligible for care, iEHR would have contributed to the care delivery of up to 25 percent of the nation’s population.

iEHR was a promise made to develop a modern EHR that would pull clinical data from two large and complex organizations through a single application and into a single database, a platform that would have been capable of incorporating advanced tools like population health and telehealth, all while satisfying the workflow needs of the largest employee-base of clinicians in the country. The cherry on top is that it was to be coded in an open-source environment, meaning that iEHR would be free to install at any facility in the country, private or public. Sound like something that would be valuable in healthcare today?

After spending $1.3 billion pursuing this promise, the VA’s CIO and CTO resigned, and the DoD announced that they’d be pursuing a commercial option instead of an open-source option. The plan was unofficially abandoned, and thus far, no one has stepped up with a plan B that would delivery anything resembling the initial promise.

Fast forward six months, and to my surprise, a conference is announced featuring some relevant, and high ranking speakers:

Seong Mun president of OSEHRA, the organization responsible for programming the VA’s current VistA platform and in line to take on coding of the new iEHR platform.

Major Hassan Zahwa, Chief in the DoD/VA Interagency Program Office, the department is led by a DoD Director and a VA Deputy Director, and is responsible for overseeing the development of iEHR and delivering on the presidents mandate for an integrated system.

Patrick Sullivan, Director of the Lovell Federal Healthcare Center in North Chicago, the nations first fully integrated DoD/VA Medical facility.

Frank Kendall was the big name that everyone came to see. Unfortunately, the Friday before the conference he cancelled. Maybe it was just a conflict of schedules, but it set an undertone at the conference that the DoD just wasn’t as invested in the project as the VA or general healthcare IT community.

Seong Mun, President of OSEHRA

Seong Mun’s presented on the work that OSEHRA is doing with VistA. He described a project being developed to standardize the VistA code set across all 151 VA facilities. A common critique of open-source systems is that there are as many variations within the code as there are users of it – meaning that everyone customizes it a bit here and there and it results in a rats nest of code to manage and integrate at an organizational level.

Seong Mun explained that the VA is actually well into a project that is standardizing the VistA codesets installed at VA hospitals and maintaining it with a new versioning control system. When he explained this, Maj Zahwa – who works in the Interagency Program Office on the iEHR program – raised his hand to clarify, asking Mun exactly what the program was, and what its goals were. He was impressed with the program, as we all were, but its disappointing that he was finding out about it now, at a public conference. This program is already well underway and the key DoD iEHR representative, a chief in the Interagency Program Office, had just found out about this plan at the same time that I had.

The DoD was supposed to evaluate both the iEHR project and the VistA alternative during the famous 30-day “We didn’t know what the hell we were doing” Chuck Hagel reset. Had they done so with any seriousness, the VistA Standardization Initiative would not have been news to someone working so closely to the core of the iEHR project. The fact that VistA is standardizing its entire code set across all VA facilities should be common knowledge among anyone holding a leadership position in the government’s Interagency Program Office.

Major Hassan Zahwa

“Lead the Departments into the future DoD/VA inter-agency electronic health record. Bridge the gap between the functional and acquisition communities though active communication and interpersonal skills.” – LinkedIn

Maj Zahwa himself presented at the conference earlier in the day. He chose to focus on the value HIEs could play in the path forward, and to that end, his presentation covered the work being done in BHIE (Bi-directional Health Information Exchange).

BHIE is an old DoD/VA HIE system installed in 2004 to replace an even older VA/DoD HIE program called FHIE. The system was in place when the need for iEHR was defined and funding was approved. But to MAJ Zahwa’s credit, there have been significant enhancements since that time and BHIE has grown into a fairly robust exchange, facilitating one million queries every month. It’s capable of sending and receiving patient demographics, problem lists, home medication lists, allergy data, lab results, radiology reports, and consult notes. If you were looking to put a rosy shine on the level of interoperability available between DoD and VA systems, the BHIE would absolutely be your topic of choice.

At this point in the conference, it was clear that the VA and OSEHRA wanted a single, integrated EHR, and that they’d been working hard and effectively to fix any perceived weaknesses in the VistA platform to eliminate DoD objections to their system. It was just as obvious that DoD wanted the freedom to buy a commercial solution, and was working on a sophisticated information exchange to validate that approach as a viable long term solution. With BHIE, the DoD was working just as hard and effectively, making significant advances that support the validity of this strategy.

It was sad that all that impressive work was being done toward two opposite ends and that these clearly very talented and task oriented teams couldn’t have aligned their goals. I suppose the silver lining to it is that no matter what happens, everyone is better of if VistA has a single code set across all the VA facilities, and everyone is also better off if the Interagency Project Office develops a robust information exchange suite that interfaces with that VistA platform. If iEHR is going commercial, as everyone seems to think it will, then both of those tools will be useful down the road. If it does not go commercial, and DoD agrees to a single VistA architecture, it will be just as useful to have versioning control for VistA and an HIE capable of pushing data out of those EHRs and into commercial systems.

Patrick Sullivan – Director of the Lovell Federal Healthcare Center

The conference closed on what was supposed to be a happy story. A shared DoD/VA hospital was opened in North Chicago and it was being held up as a model of interoperability. The hospital was used to physically examine new recruits, treat active duty sailors, and provide care to local veterans and their dependents. To the public (and in the video above) it was advertised as a true, fully integrated VA/DoD facility. Clinicians work on a mixed patient population, and an integrated EHR was necessary. It was a setting prime for a happy ending story.

Unfortunately, behind the scenes the VA and DoD could not agree on which EHR to use, so they implemented both, and care providers now have to switch back and fourth between the two systems depending on which type of patient they are seeing. Data does not flow between the two systems much better there than it does in most other VA or DoD facilities. At the end of 2012, an Institute of Medicine report identified a laundry list of serious EHR related inefficiencies. They issued a concluding recommendation that no new joint DoD/VA hospitals be opened until an interoperable or joint EHR system was made available.

The “good news” in this story was that the IT department had created a registration routine that auto-registered the patient in both systems, saving administrators a good deal of time. They had also created a single sign-on solution that opened both EHR systems, in split-screen mode, so that users could navigate and have a view of both systems in a single window. Lastly, they created a view only display that aggregated data elements from both systems and displayed it on one screen. It was not actionable data, meaning that clinicians still needed to go to the primary EHRs to place orders or document notes or take any tangible action, but it was a single location where combined data could be viewed together to tell a complete story.

The North Chicago project was a $100 million IT investment and is still operating under these conditions which, when you think about that, makes it very easy to understand how $1.3 billion was spent on a national iEHR program with so little to show for it.

My walkaway impression from this conference was that there does not seem to be an empowered leader running the iEHR program. Technology projects of this scale need a clear vision that stakeholders believe in, and a well established and empowered leader to bring the project to completion. There isn’t now, and hasn’t ever been any one person that was given ultimately responsibility and sole authority over the iEHR program.

There are too many cooks in the kitchen and the DoD leaders ultimately fight for DoD interests, while the VA leaders lobby for VA interests. In the middle, programmers at OSEHRA are trying to code an entirely new EHR with no clear direction. Someone should have been put in charge of the entire project, empowered to lead and answering only to congress, funded independently of either organization’s budget, and with the authority to make the sweeping changes that neither organization seem willing to compromise on.

In an environment so ripe with amazing leaders, I can’t believe it would be hard to find a good candidate to properly lead this project. Someone to define the vision, unify the team, and pursue it as efficiently as they’ve pursued the standardization of the VistA code or the the expansion of the BHIE structure. I mean, at very least, I think we can all agree that the staff at Lovell Federal Medical Center need to be moved to one EHR, that alone is something worth fighting for. – Lt. Dan